CLM-2026-023365
Summit Cardiovascular Associates, Cardiology. Service 2026-05-11 at office (POS 11). Received 2026-06-02.
Member
Resolved through the identity graph
- Member
- Billy Gardner
- Member ID
- UHC-71292-65
- Date of birth
- 1967-01-04
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-410675
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9255
- Coverage period
- 2022-07-01 to present
- Deductible
- $216.91 of $1,000.0022%
- Out-of-pocket maximum
- $879.69 of $2,000.0044%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5138686964
- Network
- In network
- Rendering NPI
- 7028073212
- Location
- Houston, TX · TIN 53-6389420
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $260.00 | $161.20 | — | — | DeniedCO18 |
| Totals | $260.00 | $161.20 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-904166
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-006540 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-11: SELECT-EPO (EPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-023364: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Cardiovascular Associates (5138686964). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Cardiovascular Associates2026-05-11 10:48
Patient seen for atherosclerotic heart disease of native coronary artery without angina.
- SystemSystem: Claims system2026-06-02 01:45
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-023364: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023364 | 2026-05-11 | Summit Cardiovascular Associates | $260.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Exact duplicate of an earlier submission.